Fill and Sign the Form 1aa

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE (See attached addresses) Office Use Only Date Completed Report rec’d in Regional Office ______/_____/_______ Initials: ________ SPECIAL PURPOSE - POSSESSION FOR EDUCATION - ANNUAL REPORT PERMITTEE: ____________________________________________________________ PERMIT NUMBER:_________________________ ADDRESS: _______________________________________________________________ REPORT FOR CALENDAR YEAR: _______________ _______________________________________________________________ REPORT DUE DATE: ___________________________ City State Zip Code ___Check here if reporting a change of name, address, or contact information PHONE: ___________________________ Email: _____________________________________ INSTRUCTIONS: This form is for reporting activities conducted under Special Purpose Possession Permits for both Live and Dead birds. Type or print the information requested below for all birds or parts acquired, salvaged, or held under your permit during the report year, and return the completed report to the above address by the due date. Use of this form is not mandatory, but the same information must be submitted. A supplemental sheet is available if needed. Filing an annual report is a condition of your permit. Failure to file a timely report could result in suspension of your permit. You must submit a report even if you had no activity during the year. MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT. (Ref. 50 CFR parts 13 & 21) Species Inventory (Common Name) Live (L) or Dead (D describe part) Date acquired/ salvaged Date Disposed of From whom acquired or to whom transferred (Name/Organization, City, State, Permit #), or location (landowner, city, state) where salvaged Total Number of programs the bird was used for (including on- and off-site) If on Static Display, number of days the facility was open to the public CERTIFICATION: I certify that the information in this report is true and correct to the best of my knowledge. I understand that any false statement herein may subject me to the criminal penalties of 18 U.S.C. 1001. Signature: Form 3-202-5 Date: ___________________________________________ Rev 9/2010 OMB Control No. 1018-0022 Expires 02/28/2014 SUPPLEMENTAL SHEET - SPECIAL PURPOSE POSSESSION - EDUCATION - ANNUAL REPORT PERMITTEE: ______________________ Species Inventory (Common Name) Form 3-202-5 Rev 9/2010 Live (L) or Dead (D describe part) _______ Date Acquired/ salvaged PERMIT NUMBER: Date Disposed of _____ REPORT YEAR: From whom acquired or to whom transferred (Name/Organization, City, State, Permit #), or , location (landowner, city, state) where salvaged SUPPLEMENTAL PAGE NO: Total Number of Programs the bird was used for (including on- and off-site) OMB Control No. 1018-0022 If on Static Display, number of days the facility was open to the public Expires 2/28/2014 FEDERAL FISH AND WILDLIFE PERMIT REPORT Paperwork Reduction Act, Privacy Act, and Freedom of Information Act – Notices In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a), please be advised: 1. The gathering of information on fish and wildlife is authorized by: (Authorizing statutes can be found at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.shtml.) a. b. c. d. e. Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22; Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21; General Provisions, 50 CFR 10; General Permit Procedures, 50 CFR 13; and Wildlife Provisions (Import/export/transport), 50 CFR 14. 2. Information requested in this form is purely voluntary. However, submission of requested information is a condition of your permit under the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to revoke your permit. Response is not required unless a currently valid Office of Management and Budget (OMB) control number is displayed on form. 3. Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed below, if the disclosure is compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003) a. b. c. d. e. f. g. h. Routine disclosure to subject matter experts, and Federal, tribal, State, local, and foreign agencies, for the purpose of obtaining advice relevant to making a decision on an application for a permit or when necessary to accomplish a FWS function related to this system of records. Routine disclosure to Federal, tribal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied to assure compliance with all applicable permitting requirements. Routine disclosure to Federal, tribal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and injured birds under the Migratory Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals seeking a permitted rehabilitator with whom to place a bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and injured birds. Routine disclosure to the Department of Justice, or a court, adjudicative, or other administrative body or to a party in litigation before a court or adjudicative or administrative body, under certain circumstances. Routine disclosure to the appropriate Federal, tribal, State, local, or foreign governmental agency responsible for investigating, prosecuting, enforcing, or implementing statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses, or when we need to monitor activities associated with a permit or regulated use. Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains. Routine disclosure to the General Accounting Office or Congress when the information is required for the evaluation of the permit programs. Routine disclosure to provide addresses obtained from the Internal Revenue Service to debt collection agencies for purposes of locating a debtor to collect or compromise a Federal claim against the debtor or to consumer reporting agencies to prepare a commercial credit report for use by the FWS. 4. For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number, birth date, etc.) will be removed prior to any release of the application. 5. The public reporting burden on the applicant for information collection varies depending on the activity for which a permit is requested. The relevant burden for a Special Purpose – Possession (Education) permit annual report is 1.5 hours. This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, Mail Stop 222, Arlington Square, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240. Freedom of Information Act – Notice For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any information that should be considered privileged and confidential business information to allow the Service to meet its responsibilities under FOIA. Confidential business information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The non-confidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.13(c)(4), 43 CFR 2.15(d)(1)(i)]. Migratory Bird Regional Permit Offices FWS REGION AREA OF RESPONSIBILITY MAILING ADDRESS CONTACT INFORMATION Region 1 Hawaii, Idaho, Oregon, Washington 911 N.E. 11th Avenue Portland, OR 97232-4181 Tel. (503) 872-2715 Fax (503) 231-2019 Email permitsR1MB@fws.gov Region 2 Arizona, New Mexico, Oklahoma, Texas P.O. Box 709 Albuquerque, NM 87103 Tel. (505) 248-7882 Fax (505) 248-7885 Email permitsR2MB@fws.gov Region 3 Iowa, Illinois, Indiana, Minnesota, Missouri, Michigan, Ohio, Wisconsin 5600 America Blvd. West Suite 990 Bloomington, MN 55437-1458 (Effective 5/31/2011) Tel. (612) 713-5436 Fax (612) 713-5393 Email permitsR3MB@fws.gov P.O. Box 49208 Atlanta, GA 30359 Tel. (404) 679-7070 Fax (404) 679-4180 Email permitsR4MB@fws.gov Region 4 Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virgin Islands, Puerto Rico Connecticut, District of Columbia, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Virginia, Vermont, West Virginia P.O. Box 779 Hadley, MA 01035-0779 Region 6 Colorado, Kansas, Montana, North Dakota, Nebraska, South Dakota, Utah, Wyoming P.O. Box 25486 DFC(60154) Denver, CO 80225-0486 Tel. (303) 236-8171 Fax (303) 236-8017 Email permitsR6MB@fws.gov Region 7 Alaska 1011 E. Tudor Road (MS-201) Anchorage, AK 99503 Tel. (907) 786-3693 Fax (907) 786-3641 Email permitsR7MB@fws.gov 2800 Cottage Way Sacramento, CA 95825 Tel. (916) 978-6183 Fax (916) 414-6486 EmailpermitsR8MB@fws.gov Region 5 Region 8 California, Nevada Tel. (413) 253-8643 Fax (413) 253-8424 Email permitsR5MB@fws.gov